| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
534 |
534 |
$8K |
| D1120 |
Prophylaxis - child |
378 |
378 |
$5K |
| D0330 |
Panoramic radiographic image |
112 |
112 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
266 |
266 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
82 |
58 |
$3K |
| D1110 |
Prophylaxis - adult |
122 |
122 |
$3K |
| D1330 |
|
541 |
541 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
520 |
515 |
$2K |
| D0272 |
Bitewings - two radiographic images |
227 |
227 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
519 |
509 |
$2K |
| D0274 |
Bitewings - four radiographic images |
143 |
143 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
46 |
45 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
67 |
67 |
$1K |